NETWORK - Ubhonline.com

SPRING 2003
Level of Care Guidelines and
Care Authorization Decisions
USBHPC psychologists and psychiatrists make authorization and denial decisions
on the basis of the member’s clinical information and the USBHPC Level of Care
(LOC) Guidelines. The LOC Guidelines have been developed to produce optimal
clinical outcomes and consistency in the authorization process. To assist with
the finalization of these guidelines, input was obtained from providers representing
all disciplines and from a wide geographic distribution.
Level of Care authorization decisions require agreement between the provider and
USBHPC regarding the appropriateness of the proposed treatment plan. Our care
management process offers every practitioner the opportunity to discuss a medical
necessity denial with an appropriate peer reviewer at USBHPC during the
authorization process before a final denial determination is made. Then, if a denial
determination has been made, you have the opportunity to appeal the decision
by following our Appeal process outlined in the USBHPC Provider Manual.
Both the USBHPC Level of Care Guidelines and the USBHPC Provider Manual can
be found on the USBHPC website, www.ubhonline.com or may be obtained
through the mail by calling Provider Services at 1-800-798-3053, ext. 2058.
USBHPC does not compensate employees, appeal reviewers or providers for
denials of coverage or service. There are no financial incentives for utilization
management decision-makers to encourage denial of benefits.
PRESORTED
STANDARD CLASS
U.S. POSTAGE
PAID
SAN LEANDRO CA
PERMIT NO. 311
Preventive Health
Programs
In 2003, USBHPC will be working on some
behavioral health preventive health programs.
We will be looking to the provider community
for input and advice regarding these programs,
so if you have information or ideas that might be
useful, please contact our Senior Director of
Network Management, Kimberly Davis, at
1-800-798-3053, ext. 6605.
Providers are responsible for discussing
treatment options with patients. However, not
all options will necessarily be covered benefits.
Therefore, please verify the member's eligibility
through the USBHPC Intake Department before
indicating to the member that the services are
covered benefits.
The Intake Department can be reached at
1-800-798-3053, ext. 6920.
CM325E:00
NETWORKnotes
new Spring edition!!
in this
issue
U.S. BEHAVIORAL HEALTH PLAN CA
Billing Issues
Access
Standards
Provider
Satisfaction
Survey
SM
Lifepath
Advisors Program
Communicating
with PCP’s
HIPAA
The Health Insurance Portability and
Accountability Act of 1996 ("HIPAA") became
a reality for the health care industry on April 14,
2003. HIPAA is a federal law enacted to ensure
privacy and security of a consumer’s Protected
Health Information ("PHI"). PHI is basically
defined as individually identifiable health
information that is transmitted by or maintained
in any form or medium. A few examples of PHI
include an individual’s name, social security
number or member identification number,
address, and date of birth. HIPAA is changing
the way that health care plans conduct business
with their membership, providers, partners and
contractors.
U.S. Behavioral Health Plan, California
("USBHPC") has been working diligently for over
a year to ensure all aspects of our operations
are compliant with the required HIPAA privacy
practices by April 14, 2003. USBHPC would
like to take this opportunity to share with you
some important aspects of our privacy practices
under HIPAA.
Uses and Disclosures of PHI — USBHPC has
established policies relating to requests for and
disclosure of PHI in accordance with HIPAA
and other applicable federal and state laws.
These policies ensure that only the minimum
amount of information necessary is exchanged
to accomplish the purpose of the disclosure
or request.
Use of Release of Information — It is USBHPC
policy to release PHI about Individuals only to
the Individual themselves or to other parties
designated in writing by the Individual, unless
otherwise required or allowed by law. For each
party that the Individual designates to access
their PHI, he or she must sign and date a Release
of Information specifying what information may
be disclosed, to whom, and during what period
of time. This policy is not applicable to PHI
being exchanged with a USBHPC provider or
other entity designated by HIPAA for the
purposes of Treatment, Payment, or Health
Care Operations. 1
Identification and Authentication — USBHPC
requires that anyone requesting access to PHI
be appropriately identified and authenticated.
Members and personal representatives are
required to provide the member identification
number or subscriber number and the member
or subscriber date of birth in the regular
identification and authentication process.
Providers or provider’s staff are identified and
authenticated by giving the provider’s federal
tax identification number or physical address.
This information will be required for each and
every request for access or disclosure of PHI
Internal Protection of Oral, Written, and
Electronic PHI — USBHPC works with
UnitedHealth Group, USBHPC’s grandparent
organization, to ensure that all physical and
logical safeguards are in place to protect against
the unauthorized use, disclosure, modification
and destruction of PHI across all media.
All employees of USBHPC receive training
and are familiar with the HIPAA privacy practices
relevant to their job duties and responsibilities.
www.ubhonline.com
continued

USBHPC Preferred
Practice Guidelines
USBHPC’s Preferred Practice Guidelines are treatment protocols
for specific clinical conditions. These guidelines are developed
by USBHPC on the basis of extensive literature review, scientific
evidence and expert consensus. The guidelines are intended
for Care Management staff and network providers to consider
during the treatment review process. While they identify and
describe generally recommended courses of intervention, they
are not intended to be a substitute for professional judgment
during the review of an individual patient's treatment and
situation. They simply provide you with supplemental clinical
information to support your own treatment practices.
USBHPC’s Preferred Practice Guidelines are available on our
website, www.ubhonline.com. If you would like to request a
copy by mail, please contact us at 1-800-798-3053.
Availability Standards
USBHPC is committed to ensuring that its members have the availability of behavioral health care providers to meet their mental health and
substance abuse needs. USBHPC has established standards for the numbers and types of providers, as well as for their geographic distribution.
The following standards are monitored semi-annually:
Provider Type Standard Goal 2002 Results
Physician Estimated 30 Miles 95% 93.9%
Doctoral-Level Psychologist Estimated 30 Miles 95% 99.0%
Masters-Level Clinician Estimated 30 Miles 95% 99.5%
Practitioner without Regard to Licensure Type Estimated 30 Miles 95% 99.6%
Behavioral Health Care Facilities and Programs Estimated 60 Miles 85% 96.9%
USBHPC collects and analyzes this data to ensure performance against these standards and implements interventions to improve performance
when barriers are identified. During 2003, USBHPC will be working on focused recruiting efforts in specific geographic areas to
ensure that we are providing the number and types of providers that our members need to ensure high quality care.
Access Standards
USBHPC wants to ensure that members have access to appropriate treatment as needed and, therefore, adheres to NCQA standards for
member accessibility to services. These standards require our network of physicians and other health care providers to see members within
the following time limits:
• Emergency — immediate access
• Non-life threatening emergency — within 6 hours
• Urgent — within 48 hours
• Routine — within 10 business days
Annually USBHPC collects and analyzes data to measure performance against these standards and implements interventions to improve
performance when barriers are identified. For 2002, USBHPC reports the following results:
Appointment Type
Emergency
Non-Life threatening Emergency
Urgent
Routine
2002 Appointment Access Results
100% immediate access
100% access within 6 hours
83% access within 48 hours
90% kept within 10 business days for
PhDs and Master’s Level Clinicians*
*Access for MDs is measured on an annual basis and 2002 results showed that only 75% of appointments were kept within 10 business days.
During 2003, USBHPC will continue to identify opportunities to improve our performance for urgent and routine appointments. Some of
these activities include educating providers regarding the access standards and recruitment of MDs in geographic areas that have been
identified as problematic.
In addition, the current access standards require you to return member calls within 24 hours. If you are unable to accept new patients into your
practice at this time, please contact our Provider Services Line at 1-800-798-3053, ext. 2058 so that we may temporarily suspend new referrals.
Provider Satisfaction
Survey
The 2001 Provider Satisfaction Survey for California providers
was completed in August of 2002. 519 USBHPC providers
were surveyed with a response rate of 36%. This survey was
developed to assess our providers’ level of satisfaction with
various aspects of USBHPC’s operation.
There was a dramatic decrease in satisfaction in responses to
the 2001 survey compared to 2000. Intake, Care Management,
Provider Services and Claims departments all showed a
decrease in the level of provider satisfaction with "overall
satisfaction" dropping from 87% in 2000 to 80% in 2001.
After analyzing the survey results, USBHPC has been able to
identify many opportunities for improvement. We are
enhancing our initial and on-going staff training programs
and developing new and improved technological systems
that will make it easier for providers to obtain authorizations
and will improve our claims processes. Many other initiatives
are also underway, including improved communication with
our providers via this newsletter, mailings, the provider
website, www.ubhonline.com, and a planned revision of
the Provider Manual.
USBHPC would like to thank all providers who participated in
the survey. This feedback is an invaluable tool in finding ways
to improve service to our network providers.
www.ubhonline.com
NETWORKnotes

continued
Disclosure to Plan Sponsors or Employers —
Summary health information is released to a Plan
Sponsor 2 without the authorization of the affected
Individual, as long as the Plan Sponsor needs the
information for the purpose of obtaining premium bids
or modifying, amending, or terminating the Group Health
Plan; or for providing access to employees of an employer
or Plan Sponsor to carry out administrative duties of
a Health Plan related to Treatment, Payment or Health
Care Operations.
USBHPC subscribers and/or members will receive Privacy
Notices outlining the uses and disclosures of their PHI
and their rights under HIPAA, as well as the legal duties
of their health plan to ensure protection of their PHI
under HIPAA. A copy of the USBHPC Privacy Notice
will be posted on the UBH provider website
www.ubhonline.com and will also be available in hard
copy by contacting the USBHPC Provider Line toll free at
1-800-798-3053, ext. 2058. For access to the complete
text of the HIPAA rules and regulations, please visit the
U.S. Department of Health and Human Services ("HHS")
website www.hhs.gov/ocr/hipaa/ or contact HHS Privacy
Hotline toll free at 1-866-627-7748.
1 ”Treatment, Payment, or Health Care Operations” as defined by HIPAA include:
1) Treatment – Coordination or management of health care and related services;
2) Payment purposes – The activities of a health plan to obtain premiums or fulfill
responsibility for coverage and provision of benefits under the health plan; and
3) Health Care Operations – The activities of a health plan such as quality review,
business management, customer service, and claims processing
2 "Plan Sponsor" as defined in ERISA, means the employer in the case of a Group Health
Plan maintained by a single employer, the employee organization in the case of a plan
maintained by such organization, or the committee or similar group or representatives
in the case of a plan maintained by two or more employers jointly by one or more
employers and employee organizations.
www.ubhonline.com
Billing Issues
U.S. Behavioral Health Plan, CA is aware that, on occasion,
you may experience difficulties with billing issues related
to services rendered to USBHPC members. We encourage
you to contact us at the toll-free number listed on the
back of the member’s identification card if you have
questions regarding a member’s benefits.
Our members report that billing issues may occur when
a provider charges up front for the entire cost of services
rendered instead of the co-pay/deductible, as outlined in
the member’s benefit contract, or if services are rendered
without the required pre-certification.
Please remember that requesting payment beyond a
member’s co-pay, applicable coinsurance and/or deductible
is not allowed and is in breach of your agreement with
USBHPC. To obtain more information related to billing/
claims guidelines, log on to the USBHPC provider website,
www.ubhonline.com or contact us at 1-800-798-3053.
Demographic Changes
In order to ensure ongoing participating status and minimize
problems with claims submission and payment, you must
contact USBHPC Provider Services for demographic
changes, practice changes, or when utilizing a different
tax ID number. Failure to provide timely notification of
these changes may negatively impact claims processing
and can even lead to termination. Please do not put a
new address or tax ID on a claim form. Claim information
is compared to the provider database and, if the information
does not match, the claim cannot be processed.
It is also necessary to notify USBHPC to change your status
to unavailable if you are temporarily unable to accept
referrals (e.g. vacation, illness, lack of available appointments).
Please contact Provider Services at 1-800-798-3053,
ext. 2058 or send notification to:
United Behavioral Health
Provider Database Specialists
P. O. Box 1459
Mail Route MN010-S155
Minneapolis, MN 55440-1459
Address and contact changes may also be requested
online if you are a registered user of ubhonline, our
Provider Services’ website (www.ubhonline.com). To
register and obtain an ID and password for ubhonline,
call 1- 866-209-9320.
Communication
with PCPs
It is very important that behavioral health clinicians
communicate with their patients’ PCPs. Please help your
patients get the optimum care they deserve by sending their
PCPs a brief update on diagnosis, status, prognosis, and most
importantly, psychotropic medications the patient has been
prescribed. It is not necessary to do this every time you see
the patient, but routine updates can mean a big difference
in the health outcome of the patient.
Members Identify
Education as a Primary
Consideration
Each year, USBHPC surveys its membership for satisfaction
with its operations. The results of each year’s survey are
compared to the previous year’s to identify significant changes
in satisfaction for those services surveyed. We are happy to
report that the latest Member Satisfaction Survey showed a
significant improvement in the overall satisfaction score when
compared to the prior year’s survey. Specifically, the overall
satisfaction score was 89% for the 2002 survey on services
rendered in the last quarter of 2001 compared to 82% for the
2001 survey on services rendered in the last quarter of 2000.
This was noted to exceed our goal of 83% overall satisfaction
by a statistically significant margin.
Despite this notable success, the Member Satisfaction Survey
also demonstrated that members were relatively dissatisfied
with the information received about medications being
prescribed. It was specifically noted that satisfaction dropped
from 87% in 2000 to 70% in 2001. USBHPC revealed these
results, for purposes of discussion, at the December 5, 2002
USBHPC Clinical Advisory Board meeting. The Clinical
Advisory Board recommended that providers utilize any and
all appropriate and accurate sources of information available
regarding medication education, including that information
provided by USBHPC.
For psychiatrists, the use of medications in the management
of the major mental disorders is considered to be a primary
intervention in the treatment of these disorders. Success
in the treatment of these major mental disorders is significantly
determined by compliance with medication regimen.
Compliance with taking prescribed medication is certainly
influenced by the quality of the collaboration between the
prescribing physician and the patient. Medication education
is a central part of achieving success in the medication
management of the major mental disorders. There is no
question that the use of printed material in support of
medication education further reinforces what has been
discussed during the course of appointments.
USBHPC is in the process of assessing ways in which it can
further support its provider network in the effort to educate
the membership about prescribed medications. One approach
will be the availability of "tip sheets" for behavioral health
clinicians. These "tip sheets" describe various classes of
psychotropic drugs and their actions and side effects, etc.
and are meant to be given to patients. These same "tip sheets"
were offered to PCPs in 2002 with great success. Other
approaches may include information posted on web sites and
in member newsletters.
Please take the time to educate and collaborate with
your patients regarding the use of medications.
Quality Improvement/
Utilization Management
Programs
As a contracted provider, you have the right to request
information at any time regarding USBHPC’s Quality
Improvement and Utilization Management Programs.
Here are just a few things that were done in 2002 to
improve our internal processes and to improve patient care:
• Routine phone and/or letter follow-up with every patient
being discharged from an acute care psychiatric facility to
check on availability of timely outpatient appointments
and general well being of the patient. As a result, the
number of patients who keep an outpatient appointment
within seven and thirty days following discharge has
steadily risen throughout the year. We are close to the
80% mark for the thirty-day follow-up.
• Identification and stratification of Blue Shield patients
with a co-morbid Axis III condition who are being
treated in an inpatient psychiatric setting. This has
resulted in being able to identify those patients who have
serious medical conditions as well as serious mental
health conditions, and co-manage them with Blue Shield
of California medical case managers.
• Successful recruitment efforts have grown our total provider
network by 5.7% over 2001, and our psychiatrist network
has grown by 12%.
For more information about our Quality Improvement or
Utilization Management programs, please contact us at
1-800-798-3053.
NETWORKnotes

SM
Lifepath Advisers Program
Blue Shield of California (BSC) recently launched a new program of services called Lifepath Advisers (LPA). BSC members who have their
mental health and substance abuse benefits managed by U.S. Behavioral Health Plan, California (USBHPC) will be eligible for LPA.
This new benefit is an assessment and referral service, similar to an EAP benefit, integrated with work-life and nurse line services. It is
delivered through a single toll free number, 1-866-Lifepath (1-866-543-3728), 24 hours a day, 7 days a week. Members can also register
with mylifepath.com to access information about the program, request a phone consultation online, and find additional resources.
The Work/Life service through LPA offers resource specialists who can assist members with complex issues regarding aging, chronic illness,
child development and parenting concerns. The resource counselors can also help members find local resources for child and elder care,
legal or financial needs.
Lifepath Advisers nurse advice line provides 24 hour phone access to registered nurses. BSC members can call this line for answers to
medical questions and for help in deciding how to handle minor illnesses, injuries or other health care issues.
BSC refers to the EAP portion of LPA as a “Personal Consultation” benefit in their communication materials. BSC is not marketing this service
as an EAP benefit. Members may have up to three face-to-face assessment visits, using a network provider, when clinically appropriate.
When a BSC member receives authorization over the telephone for the 3 face-to-face visits, an authorization letter, along with the appropriate
EAP claim form, is mailed to provider. Providers with questions regarding an authorization may contact an EAP counselor at 866-543-3728.
SM
Treatment Record Documentation
Appropriate and thorough documentation of a patient’s clinical history, presenting symptoms and treatment interventions are key to ensuring
appropriate patient management and continuity of care. We have developed treatment record documentation and maintenance standards,
outlined in the USBHPC Provider Manual. We expect that our panel providers and facilities will maintain their treatment records in accordance
with these standards. We would also like you to maintain an organized treatment record keeping system, as well as procedures for the
availability of patient records, appropriate to your practice site. Treatment records must be stored in a secure area and your practice site must
have an established procedure to maintain the confidentiality of treatment records in accordance with any applicable statutes and regulations.
USBHPC may review your records during a scheduled site audit. A site audit can occur for a number of reasons including: pre-credentialing
visits of potential high volume providers, reviews of facilities without national accreditation, and audits concerning quality of care issues
brought to USBHPC’s attention. The audits focus on the completeness and quality of documentation within treatment records. USBHPC
has established a performance goal of 85%. For those reviews that don’t meet the performance goal, USBHPC requests a plan for corrective
action and/or a re-audit within six (6) months.
You can find the USBHPC Provider Manual containing the documentation requirements, conveniently located on the USBHPC Internet site,
www.ubhonline.com. You may also request that a copy be sent to you by contacting Provider Services at 1-800-798-3053, ext. 2058.
Online EAP claims submission for Lifepath Advisers office visits is available via our provider Internet site, ubhonline (www.ubhonline.com).
Online EAP claims submission speeds up turn-around time and ensures greater accuracy. This website allows you to verify the status of an
EAP claim, and enables you to view and submit changes to your physical and billing addresses. All EAP claims for Lifepath Advisers
visits not submitted online should be submitted, on the EAP claim form to:
United Behavioral Health
P.O. Box 744925
Houston, Texas 77274-4925
1-800-333-8724 (for EAP claims questions)
If the BSC member requests or requires services that are covered under their Mental Health/Substance Abuse (MH/SA) benefits,
the Lifepath Advisor would refer the member to USBHPC for benefit information and appropriate authorization of services.
For members who have received services covered by their MH/SA benefits through USBHPC, claims should be submitted to:
USBHPC Claims
P.O. Box 880639
San Diego, CA 92168
877-263-9952
Members wanting additional information regarding the Lifepath Advisers program should be directed to call 1-866-Lifepath (1-866-543-3728).
ubhonline.com – A Hit with Providers
United Behavioral Health’s provider web site, www.ubhonline.com, also serves U.S. Behavioral Health Plan, California (USBHPC) providers.
ubhonline is helping providers to manage their patients and their practices. Many of you are logging on to ubhonline to submit
behavioral health and EAP claims, check on service authorizations, and review claims status. Since the new ubhonline was launched
in April 2002, the growth of transactions performed at the site has been tremendous.
• Over 21,000 confidential transactions came through ubhonline in October 2002.
• User logons have increased nearly 600% since year-end, 2001.
• First pass adjudication rates for claims submitted online exceeds 90%.
If you haven’t had a chance to try ubhonline, logon today and see what you’ve been missing. In addition to claims information,
you can find –
• Network management contact information,
• Level of Care Guidelines
• Preferred Practice Guidelines
• Provider Manual
• Patient Education and more.
Our ubhonline Support Center is available at 1-866-209-9320 from 8:00 AM to 8:00 PM Eastern Standard Time to help you with any
questions or to request a user ID.
www.ubhonline.com
NETWORKnotes